Cosmetic Surgery Online Consultation

Mailing Address

Cosmetic Surgery Enquiry *

This gives you the opportunity to discuss why you coming to see Dr Colagrande and how you are feeling, for example:
"I am unhappy with my breasts shape and size" or "I have dieted and exercised but I can’t get rid of the fat on my hips and feel out of proportion."

We would like your permission to contact your General Practitioner as necessary.

Surgical History

Have you ever had any surgery previously, cosmetic or non cosmetic. Yes No

If you are considering breast enlargement

If considering face-lift surgery

Have you tried anti-wrinkle injections or fillers? Yes No

If considering Liposuction

Have you tried to diet and exercise but have trouble loosing stubborn fat? Yes No

Medical History

Are you pregnant? Yes No

Do you smoke? Yes No

Do you suffer from?

Angina (chest pain) Yes No

Palpitations Yes No

Heart murmurs Yes No

High blood pressure Yes No

Asthma Yes No

Do you bruise easily? Yes No

Do you have any problems with bleeding or blood clotting? Yes No

Have you ever suffered from blood clots in your legs or lungs? Yes No

Kidney disease Yes No

Epilepsy Yes No

Thyroid disease Yes No

Hepatitus B / C (strict confidence) Yes No

HIV / AIDS (strict confidence) Yes No

Immune disorders Yes No

Neck or Back problems Yes No

Are you Diabetic? Yes No

Photos

This completes the necessary medical details to allow Dr. Colagrande to ensure that it is safe to consider a procedure. The next section gives additional details required to assess breast enlargement and liposculpture patients.

Photos will greatly assist Dr Colagrande in assessing your surgical needs.
Digital photographs may be attached to this form using the attachment tool below.

If you are experiencing trouble sending photos with this tool please pleased try sending them to us in a separate email to: clinic@colagrande.com.au

Feedback

We value your feedback and comments. In order for us to improve our services could you please complete the information below.

How did you hear about us?

Submit Your Information

This online consultation does not take the place of a formal consultation with Dr. Colagrande, during which a thorough physical examination, complete assessment of your needs and an in depth discussion of the procedure and possible risks will be undertaken.

DISCLAMER: I confirm that the above health history is accurate and complete. I understand that withholding any medical information will be detrimental to my health and safety.

Please type in your email address to confirm the above information is accurate and complete: